PROPOSAL FOR PUBLIC AND PRODUCTS LIABILITY INSURANCE DUTY OF DISCLOSURE Before you enter into a contract of general insurance with an Insurer, you have a duty, under the Insurance Contracts Act, 1984, to disclose to the Insurer every matter that you know is relevant to the Insurer s decision whether to accept the risk of insurance and, if so, on what terms. You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty, however, does not require disclosure of matter: that diminishes the risk to be undertaken by the Insurer; that is of common knowledge; that your Insurer knows or, in the ordinary course of business, ought to know; or as to which compliance with your duty is waived by the Insurer. NON-DISCLOSURE If you fail to comply with your duty of disclosure the Insurer may be entitled to reduce his liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning. AGREEMENT AFFECTING SUBROGATION If you have entered into any agreement which excludes or limits a right which you may have to recover damages from any person other than us, then - subject to the Insurance Contracts Act, 1984 - we will not be liable for any claim under the proposed insurance to the extent of such exclusion or limitation. In accordance with the provisions of the Insurance (Agents & Brokers) Act, 1984, Pacific Underwriting Corporation Pty Limited hereby gives notice that this contract will be effected under an Authority, given to Pacific Underwriting Corporation Pty Limited by the Insurance Companies named in the Policy. Pacific Underwriting Corporation Pty Limited will effect the Contract as an agent of the Insurance Companies and not an agent of the Insured.
PROPOSAL FOR PUBLIC AND PRODUCTS LIABILITY INSURANCE In order to calculate the premium, we take various key factors into account. These key factors include the limits of liability, the scope of cover, annual wages/salaries and turnover, your previous insurance history and the nature of your business activities. Please answer all the following questions carefully. In order to avoid delay it is important no blank spaces are left. Answers may be continued on a separate sheet of paper if designated space proves insufficient. GENERAL Full name of Proponent: Business Address: Web Site Address: Please provide a full description of your business/activities and attach any relevant brochure(s) or copy of your latest Annual Report If your business description has undergone any changes please describe previous operation(s)
INSURANCE HISTORY Are you at present insured, or have you ever been insured, in respect of the classes of insurance now proposed? If so please state the name of insurer: Has any insurer ever declined your proposal, cancelled or declined to renew your policy or imposed special terms? If so please provide full details. PREMISES How many premises are located within Australia? What is the address of your major location? How many premises are located outside Australia for which cover is required under this proposed insurance? LIMITS OF LIABILITY Please state the limits of liability required for: Public Liability: Products Liability: Pollution Liability: any one Occurrence annual aggregate annual aggregate PERIOD OF INSURANCE From: at 4:00pm To: at 4:00pm ANNUAL WAGES AND SALARIES (including earnings of principals, directors and partners) Within Australia Outside Australia Clerical and Managerial (non-manual) $ $ Manufacturing $ $ Installation $ $ Other $ $ Total $ $
ANNUAL TURNOVER Gross turnover Australia $ U.S.A./Canada $ Elsewhere $ CONTRACTORS/SUB-CONTRACTORS/LABOUR HIRE Do you engage contractors or sub-contractors or labour hire in any part of your business/activities? Yes No Estimated annual payment to contractors/sub-contractors: $ Estimated annual payment to labour hire: $ Nature of work carried out: Do you check to ensure that all contractors or sub-contractors have their own Public Liability Insurance with an adequate limit of liability and an indemnity to Principal clause? Yes No HAZARDOUS SUBSTANCES Do you process, handle or store any industrial materials that are toxic, explosive, flammable or corrosive? Yes No If Yes, please detail which substances, quantities, storage method and their use by you Are you aware of any risks to any third party persons or property arising out of pollution or contamination which may occur on or from your premises? Yes No PRODUCTS Please give details of all products in respect of which insurance is required and attach any product brochure(s) or other descriptive documents Function or end use of product Estimated annual turnover $
Is the design of these products frequently changing Yes No If Yes, please provide details: Do you design any products for others Yes No If Yes, please give full details of quality control procedures and laboratory testing used: Can you identify the source of supply of every item used in the manufacture of the products? Yes No If No, give details: Do you supply any products for nuclear, petrochemical, pharmaceutical, aviation, motor, marine or any other high risk industries Yes No If Yes, please provide details: Do you plan to manufacture/supply or introduce any new products in the next 12 months? Yes No If Yes, please provide details: Have any of you products ever been the subject of a Recall? Yes No If Yes, please provide details: Please provide a percentage split in your expected annual turnover between: Imported products or components % Exported products % Do you retain all rights of recourse against manufacturers/suppliers? Yes No
PROPERTY OF OTHERS IN YOUR PHYSICAL OR LEGAL CONTROL Cover is excluded from the insurance other than for leased premises, vehicles in car parks and employee s property. This cover will only be provided if specifically agreed by us and then subject to payment of an additional premium. If this cover is required, please advise: Do you in the normal course of business have the property of others in your physical or legal control? Yes No If yes, what is the maximum value at any one time? $ Please provide brief details of the property How is the property insured? CONTRACTUAL LIABILITY Cover for liability assumed under contract or agreement is limited to public liability (but excluding liability assumed in respect of the failure of you to effect insurances over leased property, penalties or liquidated damages or arising from the sole negligence of the indemnitee) or liability assumed under a warranty of fitness or quality as regards your products, or specifically agreed contracts. Please give full details and attach copies of all agreements where you assume liability under contract or hold other parties harmless: LEASED PREMISES Please provide details per situation of any non-owned premises: Location 1: Occupancy Construction Protection Value of Building Location 2: Occupancy Construction Protection Value of Building Location 3: Occupancy Construction Protection Value of Building Do you provide fire insurance on these buildings? Yes No
FOREIGN OPERATIONS Please provide the following details in respect of all overseas operations for which cover is required under this proposed insurance: Country Operations Annual turnover (AUD) Do you export any of your products? Yes No If Yes, please detail which products and to which countries In respect of products exported to the USA or Canada, please advise: Type(s) of products exported Annual turnover (AUD) Are you represented or do you have assets within the USA or Canada? Yes No If Yes, give full details (including copies of contracts, etc.) of all contractual agreements, terms and conditions existing between you and any USA or Canadian importer, distributor, agent or purchaser of the products exported thereto Is the USA or Canadian importer, distributor, agent or purchaser insured for Products Liability? Yes No Are you included as a named insured on such insurance? Yes No How are the products exported (e.g. F.O.B.)? For how long have you been exporting such products to the USA or Canada? NOTE: This insurance does not apply to claims made within the USA or Canada or other countries to which the laws of the USA or Canada apply other than for liability arising from specified products exported thereto and/or travelling executives or salespersons. This cover will only be provided if specifically agreed by us and then subject to payment of an additional premium
SMOKING Is smoking banned at premises occupied by you? Yes No ASBESTOS Have you ever or are you likely to produce, import, install or remove any products containing asbestos? Yes No If Yes, please provide full details: FIRST AID What first aid facilities, if any, do you maintain at your locations? Please indicate the numbers and qualifications of persons you employ: CLAIMS HISTORY during past five (5) years Public and Products Liability Please indicate details of all claims (whether insured or not) Claims Paid Outstanding Total Year Total Turnover No Amount No Amount No Amount Please supply any further information you may feel may be of use on a separate sheet of paper
DECLARATION I/We hereby declare that the above statements and particulars which We/I have read over and checked are true and that no information has been withheld which might increase the risk or influence acceptance by the Insurers and that should the above particulars alter in any way I/We will advise the Underwriters immediately. I/We have not suppressed, misrepresented or mis-stated any material fact and have fairly estimated our Wages and Salaries expenditure and Turnover and agree that this proposal shall hold promissory and form the basis of the contract between me/us and the Insurers. I/We understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the proposal may result in the Insurers refusing to provide indemnity or voiding the policy in every respect Signature of Proponent Full Name (please print) Title Date of Proposal:
PRIVACY STATEMENT AND CONSENT CLAUSES Pacific Underwriting Corporation Pty Limited is committed to protecting the privacy of the personal information you provide to us. We will use the personal information requested on this form to consider your application for public and products liability insurance. The information will also be used if you lodge a claim under your policy and to determine the premium. We may request additional information from you in connection with your application. If you do not provide us with the information in this form or any additional information we request, we may not be able to process your application or offer you insurance cover. We may disclose your personal information we collect on this form and any additional information that you provide to us in connection with this application: to our relevant staff and contractors involved in delivering our services; if a broker collects this form from you, to that broker; to the Insurance Companies named in the Policy; to any finance company, bank or other party with an interest in the business or property; to insurance reference bureaus or credit reference bureaus; to reinsurers or reinsurance brokers (which may include reinsurers located outside Australia); to facilitators such as legal firms, accountants, actuaries, engineers, valuers and others; to agents engaged by us; and if required to do so by a law enforcement body or by law. We may be required to provide your personal information to others for purposes of public safety and law enforcement. You may request access to your personal information, and where necessary, correct any errors in this information (some restrictions and costs may apply). By completing and returning this application form and/or providing us with any additional information in connection with your application, you agree to us using and disclosing your information as set out above. This consent to the use and disclosure of your personal information remains valid unless you alter or revoke it by giving us written notice. If any of your personal information changes in the future, please notify us of these changes so we can ensure that the information we hold about you is accurate, complete and up-to-date.